NHS changes: your questions answered

Doctor's desk (generic)

Fresh fears are being raised in England that cuts will have to be made to the front line of the NHS if it is to cope.

The government has promised to protect the health service, but research by the King's Fund, based on interviews with 45 NHS finance chiefs, raises doubts. The think tank said 19 expected care to get worse over the next few years and that 2013 could mark the turning point.

Meanwhile, a BBC survey of 1,005 people suggested 60% believed services would have to be cut.

In this Q&A, BBC health correspondent Nick Triggle addresses questions from BBC News users submitted via email and from social media.

Darren Pyper asks: Why are the cuts hitting front line at all? There is enough waste and useless mouths in the administration and management of the NHS to more than cover the savings expected.

Maybe it's time the BBC started switching the blame to where it belongs the managers and administrators who run the NHS. Why are they on salaries many times higher than many leading clinicians. They will argue they are managing major business but shouldn't an NHS trust really be seen as a franchise operation?

Ministers have argued money can be saved without harming the frontline. They have targeted managers - two tiers of management are going under the reforms. But there are signs the frontline is being squeezed too. Earlier this week the latest workforce figures showed the number of nurses was continuing to fall. However, this has been off-set by a rise in doctor numbers.

Reports have also emerged in recent months of an increasing amount of rationing of services. For example, an investigation by the Royal National Institute of Blind People in May found many trusts were making it more difficult to get cataract surgery done.

As for pay, that, as always, is a thorny issue. NHS statistics show that hospital chief executives are paid about £150,000 a year on average, more than the mean salaries for hospital consultants and GPs. But of course they are among the most senior managers in the sector. Further down the ladder, salaries of well under six figures are common.

Tim asks: Why, if it's true what the doom mongers say that services are suffering as a result of changes, is it that GPs in many parts of the country , do not routinely explain Choice options to patients - the very thing (market forces), that will most likely start to address poor service provision. When are the government going to force GPs to fulfil their duty to offer the best possible NHS treatment?

Choice is something every patient going for elective treatment in hospital should be offered. In April 2009 this right was enshrined in the NHS Constititution. In community services it is a more recent initiative, although it should have been rolled out in most places by now.

Opinions among GPs - like any large group of people - differ and it is certainly true there have been reports that some are less enthusiastic than others in offering choice. But ministers certainly think they should.

Both coalition ministers and, before them, those from Labour are on record arguing that the use of market forces is an important tool in driving up standards.

Andrea Warren asks: I would like to know if funding for such services as IVF will be affected during this change.

There are already signs it is happening. NHS guidelines state that infertile women should be entitled to three cycles of IVF, but in many areas that is not possible. In fact, the NHS has some of the poorest access to fertility treatment in Europe, according to the European Society for Human Reproduction and Embryology.

But IVF is not the only area which seems to be affected. As I have mentioned already, there are reports cataract surgery is being hit, while a host of other services from varicose vein treatment to hernias are not always routinely available.

The NHS is certainly entering a crucial few years. The budget is only rising by 0.1% a year this parliament - the longest sustained period of virtually zero growth - and many fear that this will lead to more cuts to services. It is a concern raised today both by the King's Fund and BBC poll.

Alec Melvin asks: What happens when your GP or Commissioning Group reaches the limit of their budget? Can they overspend or do we have to go private?

Not balancing the budget is nothing new in the NHS. It has always happened. Traditionally, money has just been moved round the health service so those in surplus bail out those who have run up deficit.

In recent years there has been more attention on getting individual areas to balance their books. It is quite common for those that find themselves heading towards a deficit to start slowing down the pace at which they send people for treatment - and the same could certainly be seen among commissioning groups in the future.

But it would be virtually impossible for every area to balance its books every year and so expect some to run up deficits. When this happens patient care will not grind to a halt as regional chiefs will always keep services running in the short term. But commissioning groups would be put under pressure to find a solution.

In basic terms, they would have one of two choices: to stop doing things or to do them more efficiently.

On the BBC News Facebook page, Thomas Gibbs asks: How does this make the NHS better?

Manopriya Yessu asks: How many are happy with GPs as doctors? I agree they should learn management skills too but their first preference should be treating patients well. GPs are already complaining about how much paper work, form-filling they need to. They don't have time to treat people. Giving extra responsibilities - how does it going to help patients?

I have answered these two questions together as they both raise a similar point.

The theory is that by giving GPs control of the NHS budget the service will become more responsive to the needs of patients. As GPs see people day in, day out they are familiar with what they need and what frustrates them.

That in turn, or so ministers say, should give them a better insight into where to channel funds. Meanwhile, inviting other providers to compete for work with NHS bodies will help to drive up standards.

Of course, many would argue that something like healthcare cannot be left completely to the open market. For example, there are services in rural areas that would not be profitable but which have to be provide to ensure care is available universally. But ministers say there are enough checks and balances in the system to ensure vital services are not harmed, while getting the NHS, private and not-for-profit sectors to compete where appropriate.

As for whether GPs are happy or not with this new responsibility, the answer is it depends who you ask. The Royal College of GPs and the British Medical Association have both expressed strong reservations about the plans.

However, those who do not want to get involved with managing the budget won't have to. In reality only a small number of GPs in each group will get involved in that side of things - and plenty of those have come forward so far.

Andy Jeavons asks: Do you know how the changes will affect the 'choose & book' system? At the moment, the NHS constitution gives the patient the right to choose treatment at any NHS hospital anywhere in the uk. Will this still be the same after the changes?

The NHS Constitution only applies to England. But yes choice will remain in place after the reforms kick in. In fact, choice is at the heart of the government's plans and is currently being extended in to community services such as podiatry, hearing and counselling to complement the options on offer for hospital patients.

Stephen Smith asks: I have heard that the NHS, according to OECD figures, is one of the lowest cost, fairest and most efficient health services in the world. Why is it that we are constantly bombarded with one sided information to the contrary on almost all forms of media. Are we being fed propaganda for political idealism?

There is, of course, much to celebrate about the NHS. The Commonwealth Fund, a US-based think tank, which has been comparing health systems in recent years has been full of praise for the NHS, comparing it favourably with many other developed health systems when it comes to things such as waiting times and use of technology.

OECD data has tended to be a bit more ambiguous. Much of its figures focus on how well health systems do with treating disease. In areas such as cancer and heart disease there are other systems that do better, but there are signs the NHS is closing the gap.

Marianne MacDonald (on behalf of the Self Care Forum) asks: Should the NHS be doing more to encourage people to self care? Around 1 in 5 visits to a GP surgery are for minor ailments, such as headache, heartburn, coughs, sore throats, back ache and sprains and strains. These can often be easily managed through self care, with additional help from the pharmacist.

Providing the education and support to enable people to look after their own health has been estimated to cut down the 57 million GP consultations each year for minor ailments, and potentially save the NHS £2bn. This would not only go some way to help meet these budget targets, but would free up GPs and practice nurses to focus on more serious conditions.

There has been a big push to help reduce unnecessary attendances across the health service, whether they are in GP surgeries or A&E units. Pharmacists have been given extra training so they can answer a host of questions people would traditionally have visited a GP to ask.

But GPs still remain the gateway to the NHS, something that is not always the case in other countries. It means patients will often turn to them when they have concerns. But most doctors would acknowledge that there are times when they have had patients come and see them when it has not been necessary.

Jeanette Riseley asks: Why are NHS Trusts allowed to have so many managers who earn very high salaries (way above qualified nurses)? If every Trust reduced their management staff and Matrons by one per Division, then there would be a huge saving.

It is fair to say managers in the NHS feel unfairly maligned. They point out that the health service is an organisation with a budget of well over £100bn, employing over one million staff.

It is true that over the last ten years the number of managers has increased at a faster rate than the number of nurses or doctors. However, they have also started falling at a faster rate. Last year the number of managers and senior managers fell by 9% to under 40,000 in England. I have already mentioned the issue of their pay.

But one question worth asking is what would happen if the number of managers were cut to the bone? A report last year by the King's Fund concluded the NHS was not over managed and if they were cut too much it could pose a risk to financial control and quality of care.

Terence Ogden asks: Why is it that the cuts are related to England? We are the only ones who pay for prescription/car parks in hospitals. I thought it was the National Health Service not the English?

Health policy is devolved which has allowed Scotland, Wales and Northern Ireland to pursue the policies you mention. In England ministers have argued on both points that they are not affordable and money is better invested elsewhere. However, it is also worth saying that there are policies and practices patients in England have benefited from that others elsewhere in the UK haven't. For example, waiting times for non-emergency operations, such as knee and hip replacements, dropped much sooner and by more in England than in Scotland, Wales and Northern Ireland.

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